ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Establish a plan of care with the client that sets attainable goals. This is because involving the client in setting realistic goals can empower them and increase motivation for rehabilitation. By collaborating with the client, the nurse can address the client's needs and preferences, leading to a more personalized and effective rehabilitation plan. Encouraging the client to actively participate in their care promotes autonomy and fosters a sense of control over their situation.
Other choices are incorrect:
A: Encouraging the client to discuss their feelings is important, but it may not directly address the need for a structured plan of care with attainable goals.
C: Increasing the frequency of physical therapy sessions may be overwhelming for the client and not address the underlying issue of lack of motivation.
D: Allowing the client to set the schedule for rehabilitation may not provide the structure and guidance needed for effective rehabilitation.
Question 2 of 5
A nurse is caring for a client with a sucking chest wound from a gunshot. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. This is the priority action to ensure the client receives adequate oxygenation. In a sucking chest wound, air enters the pleural space, leading to a potential pneumothorax, which can compromise oxygenation. Administering oxygen helps maintain oxygen saturation levels and supports respiratory function. Placing the client in Trendelenburg position (choice
B) can worsen respiratory distress by increasing pressure on the diaphragm. Applying a warm compress (choice
C) may promote bleeding and is not effective in managing a sucking chest wound. Encouraging deep breathing exercises (choice
D) can further exacerbate the pneumothorax by allowing more air to enter the pleural space.
Question 3 of 5
A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects?
Correct Answer: D
Rationale: The correct answer is D: Adrenocortical insufficiency. Gradually reducing prednisone dose is important as prednisone suppresses the body's natural production of cortisol. Abrupt discontinuation can lead to adrenal insufficiency due to the sudden decrease in cortisol levels. This can result in symptoms such as fatigue, weakness, weight loss, and hypotension. Osteoporosis (
A) is a long-term side effect of prednisone but not a concern with dose reduction. Hypoglycemia (
B) and Hyperkalemia (
C) are not typically associated with prednisone withdrawal.
Question 4 of 5
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection.
Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
Question 5 of 5
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma rarely metastasizes to other parts of the body, making it highly curable through surgical excision. This information is crucial for patients to understand the low likelihood of the cancer spreading.
Choices B and C are incorrect because basal cell carcinoma is not typically fatal nor does it metastasize early.
Choice D is incorrect as basal cell carcinoma is more common in older adults, not younger clients.